Massage Therapy for People with Dupuytren's Disease
/Massage Therapy for People with Dupuytren's Disease
Dupuytren's disease (also known as Dupuytren's contracture) is a progressive fibroproliferative disorder of the hand, characterized by fibrous nodules that may eventually cause disabling contractures of the affected fingers. Typical presentation is a gradual onset in males over 50 years of age. At first people may not notice the development of changes in their palms, the condition may even go dormant, but if the palmar fascia begins to thicken and contractions develop, the condition is recognizable - this is the ideal time to seek help from massage therapy.
Pathophysiology
The progression of the disease is a complicated process, involving a cascade of molecular and cellular events, in which the cytokines transforming growth factor beta (TGF-β) and tumor necrosis factor (TNF) play a fundamental role during the course of Dupuytren's disease. Elevated levels of TGF-β & TNF contribute to the contractile activity of myofibroblasts, which drives disease development, in patients with Dupuytren's contractures (Schuster et al., 2023). This leads to a thickening of the tendons of the forearm and the palmar fascia, which causes the fingers to flex toward the palm.
Pathophysiology of Dupuytren contracture (from Lambi et al., 2023).
Informed Consent and Shared Decision Making
Informed consent will include a discussion about natural history and the effects of no treatment, as well as the possible risks and benefits of receiving treatment. The therapist and patient will then work together to develop a plan of care based on the individualized goals and needs of the patient. This approach gives people the opportunity to be engaged in their own health through the process of shared decision making.
Assessment
A comprehensive assessment assists the clinician come up with a treatment plan that is best suited to each individual. It may involve a physical assessment and detailed health history intake to gather information about patients' limitations, course of pain and can help identify those with a higher likelihood of red flags (serious underlying pathologies) or yellow flags (prognosis factors for delayed recovery). This may also help establish therapeutic alliance and identify the biological, psychological, social and contextual factors contributing to pain and disability.
Red Flags (serious underlying pathologies) - Red flags are signs and symptoms that raise suspicion of serious underlying pathology, if a serious pathology is suspected a clinical decision should be made to refer the patient to an appropriate healthcare practitioner. For the general population there are several red flags to be mindful of such as, substantial motor/sensory loss or progressive neurological deficits, fractures or osteoporosis risk/fragility fracture, acute infection (fever/chills/malaise), joint dislocation, peripheral arterial disease and venous thromboembolism.
Yellow Flags (risk factors for delayed recovery) - This assessment process could also include screening questionnaires, such as the Orebro musculoskeletal pain questionnaire or Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) to help identify yellow flags or identify patients at risk of poor prognosis. If the patient develops worsening physical or psychological symptoms consider a referral to counseling or an appropriate healthcare professional for further evaluation.
Physical Assessment - A physical assessment could include palpation, observing gait, neurological screening tests, assessing mobility and/or muscle strength. Interpret assessment results in the context of all assessment findings and implement an individualized treatment plan that is based on the assessment findings and goals of the patient.
Outcome Measurements
Clinicians should use appropriate tools and strategies to monitor and evaluate the effectiveness of the treatment plan and adapt care accordingly. This could include incorporating one or more of the following outcome measurements when assessing and monitoring patient progress:
Self-Rated Recovery Question
Patient-Specific Functional Scale (PSFS)
Brief Pain Inventory (BPI)
Visual Analog Scale (VAS)
DASH Outcome Measure
Upper Extremity Functional Index
Patient-Rated Wrist Evaluation (PRWE)
Patient-Rated Wrist/Hand Evaluation (PRWHE)
Orthopedic Tests
Clinicians could also incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.
Allen Test
Tinel’s Sign
Froment’s Sign (Pinch Grip Test)
Treatment
Education
Focus on the concept of a person-centered approach that addresses biopsychosocial influences and empowers people with shared decision-making. Provide reassurance and facilitate an evidence based understanding of treatment options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms. Reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery.
Manual Therapy
Studies have demonstrated that non-operative treatments such as massage therapy combined with active and passive stretching may affect progression (Fernando et al., 2024). As a therapeutic intervention massage therapy has the potential to attenuate TGF-β1 induced fibroblast to myofibroblast transformation. Researchers have looked at the effect of modeled massage therapy and mechanical stretching on tissue levels of TGF-β1. In these studies, it was demonstrated that manual therapy has the potential to attenuate tissue levels of TGF-β1 and the development of fibrosis (Bove et al., 2016; Bove et al., 2019). This is potentially impactful in the treatment of Dupuytren's disease because TGF-β1 plays a key role in tissue remodeling and fibrosis.
Treatment focus is on the intrinsic hand muscles and carpal bones of the wrist, while also addressing areas of compensation, such as the flexors and extensors of the forearm. Massage therapy may delay the progression of contractures and decrease recurrence in post-operative patients. Massage therapy treatment for Dupuytren's disease should not be vigorous and stretching should be a gentle exploration of range of motion. A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from Dupuytren's may include neurovascular structures and investing fascia of:
Biceps Brachii (bicipital aponeurosis)
Triceps Brachii
Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris)
Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
Anterior Interosseous Membrane
Palmar Aponeurosis
Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)
Lumbricals
Self-Management Strategies
Tension and compression orthotic devices and splinting is often used after surgery in the short term. This has been shown to reduce the chances of recurrence in some people. Long term use of orthotic devices and splinting has mixed evidence. There have been modeled experiments to demonstrate the impact of stretching on inflammation-regulation mechanisms within connective tissue. Patients should be educated on the benefits of gentle stretching routines. Stretching should not be vigorous, it should be a gentle exploration of range of motion.
Prognosis
There is a high rate of recurrence in the post-operative population. In the early stages a trial of conservative care is the preferred treatment approach, this often includes manual therapy, night splinting, and home hand exercises. Persistent inflammation has the potential to interfere with the tissue remodeling, early conservative interventions may serve to interrupt the sequelae of pathological healing. The ideal treatment for patients with progressive Dupuytren's disease would be at the early stage to prevent or delay the development of flexion deformities and loss of manual dexterity. Prophylactic massage therapy treatments may inhibit inflammatory processes and affect the development of fibrosis by mediating differential cytokine production. Consequently, this may stabilize the progression of contractures and in some cases ameliorate the degree of deformity.
Clinicians should work in partnership with patients to develop a person-centered care plan that considers best available evidence and the patient's goals, values, and preferences. If appropriate, start with multi-modal conservative care (education and reassurance, exercise, manual therapy, hydrotherapy, acupuncture, etc.) and reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery. Then the patient is discharged, treatment is continued, or treatment is escalated based on response to the initial treatment plan, risk/benefit assessment and shared decision making.
Key Takeaways
Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for Dupuytren's disease based on patient-specific assessment findings including, but not limited to:
Manual therapy (soft tissue massage, neural mobilization, joint mobilization)
Education and advice (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
Remedial exercise programs incorporating stretching, strengthening, and physical activity
Self-management strategies (e.g., mindfulness-based interventions, hydrotherapy, engaging in physical activity and social activities, and healthy sleep habits)
References and Sources
Barbe, M. F., Harris, M. Y., Cruz, G. E., Amin, M., Billett, N. M., Dorotan, J. T., Day, E. P., Kim, S. Y., & Bove, G. M. (2021). Key indicators of repetitive overuse-induced neuromuscular inflammation and fibrosis are prevented by manual therapy in a rat model. BMC musculoskeletal disorders, 22(1), 417. https://doi.org/10.1186/s12891-021-04270-0
Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. https://doi.org/10.1016/j.jns.2015.12.029
Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., Chapelle, S. L., & Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. https://doi.org/10.1097/j.pain.0000000000001443
Christie, W. S., Puhl, A. A., & Lucaciu, O. C. (2012). Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren's contracture: a prospective case study. Manual therapy, 17(5), 479–482. https://doi.org/10.1016/j.math.2011.11.001
Dutta, A., Jayasinghe, G., Deore, S., Wahed, K., Bhan, K., Bakti, N., & Singh, B. (2020). Dupuytren's Contracture - Current Concepts. Journal of clinical orthopaedics and trauma, 11(4), 590–596. https://doi.org/10.1016/j.jcot.2020.03.026
Fernando, J. J., Fowler, C., Graham, T., Terry, K., Grocott, P., & Sandford, F. (2024). Pre-operative hand therapy management of Dupuytren's disease: A systematic review. Hand therapy, 29(2), 52–61. https://doi.org/10.1177/17589983241227162
Hinz, B., & Lagares, D. (2020). Evasion of apoptosis by myofibroblasts: a hallmark of fibrotic diseases. Nature reviews. Rheumatology, 16(1), 11–31. https://doi.org/10.1038/s41584-019-0324-5
Lambi, A. G., Popoff, S. N., Benhaim, P., & Barbe, M. F. (2023). Pharmacotherapies in Dupuytren Disease: Current and Novel Strategies. The Journal of hand surgery, S0363-5023(23)00070-9. Advance online publication. https://doi.org/10.1016/j.jhsa.2023.02.003
Schuster, R., Younesi, F., Ezzo, M., & Hinz, B. (2023). The Role of Myofibroblasts in Physiological and Pathological Tissue Repair. Cold Spring Harbor perspectives in biology, 15(1), a041231. https://doi.org/10.1101/cshperspect.a041231
Soreide, E., Murad, M. H., Denbeigh, J. M., Lewallen, E. A., Dudakovic, A., Nordsletten, L., van Wijnen, A. J., & Kakar, S. (2018). Treatment of Dupuytren's contracture: a systematic review. The bone & joint journal, 100-B(9), 1138–1145. https://doi.org/10.1302/0301-620X.100B9.BJJ-2017-1194.R2
Stecco, C., Macchi, V., Barbieri, A., Tiengo, C., Porzionato, A., & De Caro, R. (2018). Hand fasciae innervation: The palmar aponeurosis. Clinical anatomy (New York, N.Y.), 31(5), 677–683. https://doi.org/10.1002/ca.23076
Younesi, F. S., Miller, A. E., Barker, T. H., Rossi, F. M. V., & Hinz, B. (2024). Fibroblast and myofibroblast activation in normal tissue repair and fibrosis. Nature reviews. Molecular cell biology, 10.1038/s41580-024-00716-0. Advance online publication. https://doi.org/10.1038/s41580-024-0071 6-0